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Let me take an example of more common problem of fever and how economy decides the level of care. In a general out-patient care 80% of patients will be infections. Another fact that we have to remember is patients in low socio economic status earn about $4-6 a day, on which the whole family lives. The wage earner takes leave, the whole family suffers. In this situation let us say this wage earner gets a fever. He usually waits for a day or two to see if it subsides by itself or by medications taken form the local pharmacy (Which can be something simple from Acetaminophen to antibiotic to sinister steroids). When he comes to the doctor, he wants fast and economical relief. He does not have the luxury of taking rest for three days to observe whether it is viral or bacterial or the character of the fever. The more days he is unwell the more his family is suffering. He is willing to spend a little bit for a fast relief. In this situation, the doctor is in a dilemma – should he treat like in an ideal situation -give symptomatic relief and wait then start an antibiotic Versus start an antibiotic for the benefit of doubt and see that he is back to normal without the need to come back. While the later is less than ideal or maybe irrational also, many practioners do that only. As long as the antibiotic is cheap and the patient can complete the course, he is not going to propagate resistance. For resistance comes mainly because of discontinuing antibiotics before the course completion. The problem comes when practioners start using more and more expensive narrow spectrum antibiotic pushed to them by medical representatives. Then the patient is exposed to a costly medication with more chance of default and resistance. (Eg Doxycycline costs 12.5 cents a course compared to 10$ for Co-amoxi-clauv). The second problem comes when we do the same thing to people who can afford, for who the standard regime can be followed. This is very common, you go to a corporate hospital, the patient is spending a lot of money to see the consultant and of course he does not disappoint the patient but gives him the cutting edge, wallet cutting antibiotic for a common cold. Conscious judgment is necessary to try to see the social situation of the patient, his clinical condition before appropriate course cannot be taken. There is no single guideline for all patients.

Money determines many things in places where insurance is not in place like India. Whether a patient is going to undergo thrombolysis or just heparin for myocardial infarction, thrombolysis for an acute stroke or just aspirin or for that matter any treatment becomes dictated by how much he/she can spend. Let us say a patient comes with chest pain and you need an electrocardiogram (Costs $2.5), a few of them are not able to afford. But if a Trop-T is suggested, most of them cannot afford. Then the dependence of diagnosis goes to enzyme levels and serial electrocardiograms which is going to delay the treatment. So it is not the question of availability but the question of affordability. Many people cannot afford thrombolysis (Drug alone cost about $50, which is a month’s salary for many people. We should remember, with thrombolysis other cost like stay in ICU, investigations are going to add up to a big packet). Of course the government is doing a great job of stocking Streptokinase for thrombolysis in all major government hospitals for free use. But then it has to be rationed. If say 5 doses are available for a month, you will tend to reserve it for an young patient than a older patient with infarction, though it will save more of the later. So how much a patient can afford, will determine the standard of care the patient is going to get. I will put in my next post another day to day problem of treating fever, where money determines ideal vs less than ideal care.

About an year ago, a retired engineer came to me for uncontrolled hypertension. At the time of presentation, he had mild dementia which continued to progress, despite adequate control of hypertension. His CT of the brain showed multiple lacunar infarcts. Over the year, i have been seeing him and his dementia has unfortunately continued to worsen. He lives with his wife who has, i think, severe arthritis because of which he has to do most of the house-hold activities like cooking, taking care of the house, catching water from the municipal pipe in the street.. They do not have / want any servants. The point i am trying to make is not about his medical condition but the social one. His son and daughter are well settled in nearby towns. The patient in question has developed a tendency to fall repeatedly (Luckily has not developed any fractures yet). But no social support. When i saw him last, he was starting to get confused a lot. Not remembering when to take pills… I have talked to both his children about it. They are not willing to either take their parents with them nor willing to come & stay with him. The main reason being his quirkiness and rigid thoughts. I am sure most of our parents, when they become old become quirky in their thoughts and have lot of difference in opinion from ours. But is that reason enough to leave them to suffer like this. Is this what we payback to someone who sacrificed so many innumerable things to see us being happy? Sure the above mentioned patient’s children are willing to give monetary help. But can money buy peace to their parents? I am sure when we get old, we are going to become out of tune with what our children think and want to do. But our children are learning from what we are doing. They will also learn to neglect us if we neglect our parents. And this is the least important reason for taking care of our parents. We should take care of them for what they were when we were children, for all the sacrifices they did and for all the hardships that they tolerated from us. Probably taking care of them when they are old & fragile is the least payback we can give to all they gave & gave-up for us.

PS: A kind friend of mine, who has not seen this post, forwarded this powerpoint presentation to me which i thought was apt to be put here. Since it does not have an author/source, i am not able to acknowledge the author.

In the recent days i see a lot of ads in the newspapers about, e-bikes – pollution free electric vehicles. These ads tout the supposed advantage of economy, noiselessness and with an added benefit of helping the environment. There is an electric car also in production. Are these not mis-informations? In India, like in most countries around the world, majority of the electricity is produced from fossil fuels. So how do you cut pollution when you use electricity produced from fossil fuel to charge your vehicle? Less smoke, less noise, economical… acceptable with a pinch of salt. No pollution – not acceptable. But to most who read these ads this is not apparent. This is taken to advantage by the sellers. Is it ethical?

In practice we see a lot of patients that we know at a personal level and treat them without any consulting fees. We spend more time explaining to them about the disease and clarifying their doubts then the usual run of the mill patients. But these are the people who become a failure to us. Failure in that, most of them do not comply with the advises as much as patients who wait their turn to see us and pay out of their pocket for the consultation. (Of course this applies to places like where i live where there is medical insurance is not popular). This is sad because the people who you really want to take care are the people who end up getting the least care. I have along list of such patients – a relative who is obese and constantly has under-controlled blood pressure, a colleague’s wife who has diabetes and gone to develop albuminuria, i can keep on making a long list. But the underlying theme in all these patients is, they do not pay for their consultation and do not comply. Is it because they do not wait for an hour in the waiting room (Because i see them right away) make them think that the doctor that they are consulting is not good? Is it because they are not paying for the advice, they do not feel that it is important? Or is it just the feeling that at anytime you can consult the doctor and he will take care of you despite not following any of his advice the reason for non-compliance? Whatever the reason, it is sad. So what i have started doing is not to give any undue advantage to people who i know. Collect the fees in most situations, advice them as i would to any patients and be strict that they comply . Even though this may make them feel bad at the beginning i feel that this is what is good for them in the long run.

In this post i write about two unforgettable patients. The first one was a patient in his forties a smoker with diabetes, hypertension and hyper-lipidemia. He went on to develop exertional angina. His electrocardiogram showed ischemia at rest and an echocardiogram revealed regional wall motion abnormalities in the areas corresponding to the ischemia. He was started on nitrates in addition to aspirin he was already on. He was not willing for angiogram or any other procedures. His angina worsened to a stage where he was hardly able to walk for five minutes before getting angina. The nitrates had been increased to the maximum and calcium channel blocker and beta-blockers had been added without much use. i expected him to go for infarction any day. He asked me whether there was any other medications for relieving his chest pain.When i said there was none, he went for alternative treatment (Unani). He came after a few days and told me, that he was pain free and had stopped all the nitrates. I was happy for him but still expected him to be brought with infarction one day. He continues to smoke, has stopped all medications other than his anti-diabetics, including aspirin and is pain free. Not only that, his sugars are normal with nearly half the medications he had been prescribed. It is nearly five years now.This was one patient who brought me, belief in alternative medication. Each time i see him, i am surprised at what true alternative medicines can do. In this era of science and evidence medicine, it made me believe there are many things which can be learn from true practioners of alternative treatments.It also made me believe absence of evidence does not mean lack of evidence.The second patient is a patient again a non-hypertensive, poorly-controlled diabetic, who came with three hours history of difficulty in speaking. On examination he had evidence of lower cranial nerve paresis (7, 9 & 10) with recurrent aspiration and dysarthria. He could not afford an CT of the brain at admission.So i started him on aspirin. He recovered dramatically and within eight hours he was totally asymptomatic. At this time the attendees were willing for a CT. The CT revealed a cortical infarct on the opposite side. So what he probably he had was a brain stem TIA with a old asymptomatic cortical infarct. He was taken against medical advice after the CT for alternative treatment.I was surprised. Usually patients go for these when the treatment they are taking fails, not when it is improving dramatically. I have found, for strokes these patients get nothing but a good physiotherapy.The problem is they stop the secondary prophylaxis and invariably end-up in recurrent stroke.This patient has not come back to me but i have seen many patients with ischemic strokes on alternative therapy going for recurrent stroke without aspirin prophylaxis.So what is the conclusion. There are areas where alternative therapies hold big promises. There are areas where they fail miserably. The failure may be because of people who do not know these therapies practicing the art (Probably the main cause. You can get a degree in any of the alternative therapies by distant education in six months flat!) or because there is no real treatment in that system.It is our duty to find evidence for therapies where it seems to be obviously successful. Once we have positive evidence, more people will search for evidence and the ultimate benefit is of course to the patients of these chronic diseases.

This time the grand rounds was held in Africa at one of my favorite blog spots.It had a few good articles that were worth pondering about. The one by rlbates on hematomas in plastic surgeries. Makes us understand some logical reason (hypotensive anesthesias to create a bloodless field during surgery) can go wrong due to a better logical explanation. (After closing the wound and blood pressure coming to normal small bleeders not cauterized during surgery bleeding and causing hematomas).The other article (Extend the spirit of Christmas) which makes us start thinking why we get the helping mentality only during festive seasons and make us feel that, the same attitude should last throughout the year.I liked ‘good suggestions’ and ‘resolutions for doctors and patients’ which made me think of those suggestions and new year resolutions seriously. Simple yet very much necessary. The ones about brain fitness in ‘expensive brains’ was also great. Susan’s article on ‘night of trauma’ takes us through the agony of human life, death and suffering. All in all more exposure to me to these fantastic writers. If any of you visiting my blog have the time, do visit to ponder further.